<!DOCTYPE html>
<html>
	<head>
		<meta charset="utf-8" />
		<title>第二周周考技能效果</title>
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	</head>
	<body>
		<!-- 页面名称 -->
		<h1 style="border-left: black 5px solid; padding-left: 20px; margin-left: 20px;">在线预约</h1>
		<!-- 水平线 -->
		<hr style="border: gray 1px solid;">
		<!-- 表单 -->
		<form class="form-horizontal">
			<!-- 体检地点-文本框 -->
			<div class="form-group">
				<label for="inputEmail3" class="col-sm-2 control-label">体检地点</label>
				<div class="col-sm-9">
					<input type="text" class="form-control" id="inputEmail3" placeholder="请选择">
				</div>
			</div>
			<!-- 体检类型-文本框 -->
			<div class="form-group">
				<label for="inputPassword3" class="col-sm-2 control-label">体检类型</label>
				<div class="col-sm-9">
					<input type="text" class="form-control" id="inputPassword3" placeholder="请选择">
				</div>
			</div>
			<!-- 您的姓名-文本框 -->
			<div class="form-group">
				<label for="inputPassword3" class="col-sm-2 control-label">您的姓名</label>
				<div class="col-sm-9">
					<input type="text" class="form-control" id="inputPassword3" placeholder="">
				</div>
			</div>
			<!-- 您的性别-单选框 -->
			<div class="form-group">
				<label for="inputPassword3" class="col-sm-2 control-label">您的性别</label>
				<div class="col-sm-1">
					<label class="radio-inline">
						<input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 男
					</label>
				</div>
				<div class="col-sm-1">
					<label class="radio-inline">
						<input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 女
					</label>
				</div>
			</div>
			<!-- 婚姻状况-单选框 -->
			<div class="form-group">
				<label for="inputPassword3" class="col-sm-2 control-label">婚姻状况</label>
				<div class="col-sm-1">
					<label class="radio-inline">
						<input type="radio" name="inlineRadioOptions" id="marry" value="yihun"> 已婚
					</label>
				</div>
				<div class="col-sm-1">
					<label class="radio-inline">
						<input type="radio" name="inlineRadioOptions" id="marry" value="wenhun"> 未婚
					</label>
				</div>
			</div>
			<!-- 预约时间-文本框 -->
			<div class="form-group">
				<label for="inputPassword3" class="col-sm-2 control-label">预约时间</label>
				<div class="col-sm-9">
					<input type="date" class="form-control" id="inputPassword3" placeholder="请选择">
				</div>
			</div>
			<!-- 通信地址-文本框 -->
			<div class="form-group">
				<label for="inputPassword3" class="col-sm-2 control-label">通信地址</label>
				<div class="col-sm-3">
					<input type="text" class="form-control" id="inputPassword3" placeholder="请选择">
				</div>
				<div class="col-sm-3">
					<input type="text" class="form-control" id="inputPassword3" placeholder="">
				</div>
				<div class="col-sm-3">
					<input type="text" class="form-control" id="inputPassword3" placeholder="">
				</div>
			</div>
			<!-- 联系电话-文本框 -->
			<div class="form-group">
				<label for="inputPassword3" class="col-sm-2 control-label">联系电话</label>
				<div class="col-sm-3">
					<input type="tel" class="form-control" id="inputPassword3" placeholder="中国大陆+86">
				</div>
				<div class="col-sm-6">
					<input type="tel" class="form-control" id="inputPassword3" placeholder="">
				</div>
			</div>
			<!-- 过往病例-文本域 -->
			<div class="form-group">
				<label for="inputPassword3" class="col-sm-2 control-label">过往病例</label>
				<div class="col-sm-9">
					<textarea class="form-control" rows="6"></textarea>
				</div>
			</div>
			<!-- 提交按钮 -->
			<div class="form-group">
				<div class="col-sm-offset-2 col-sm-10">
					<button type="submit" class="btn btn-primary" style="padding: 10px 80px; "><a href="submit-success.html" style="text-decoration: none; color: white;">提交</a></button>
				</div>
			</div>
		</form>
		
	</body>
</html>
